Current concepts in the management of heart failure

Objective: To review current concepts in the management of patients with heart failure. Data sources: A review of articles reported on acute and chronic heart failure. Summary of review: Heart failure has been defined as that state which occurs when the heart fails to maintain the needs of the body despite a satisfactory venous return. While it has been divided functionally into high-output failure and low-output failure, it is often used to describe patients with left ventricular low-output failure and is divided into systolic or diastolic heart failure, depending on left ventricular ejection fraction. The clinical features are due largely to venous congestion and reduction in cardiac output with symptoms of fatigue, orthopnoea, paroxysmal nocturnal dyspnoea and peripheral oedema being common complaints. Plasma natriuretic peptide levels are elevated in patients with symptomless left ventricular failure and have been useful in diagnosing heart failure in patients admitted with acute dyspnea. Treatment of heart failure is aimed at correcting both the underlying disorder as well as the precipitating cause (eg ischaemia, valvular heart disease, anaemia, thyrotoxicosis, etc), as well as reducing cardiac work, enhancing myocardial contractility and treating the complications (eg reducing salt and water retention, and neurohumoral activation). Angiotensin converting enzyme (ACE) inhibitors, angiotensin receptor antagonists, beta-blockers and spironolactone have all been associated with a reduction in mortality in patients with chronic heart failure. While digoxin and diuretics are used to reduce the number of episodes of pulmonary oedema, they have not been associated with a significant reduction in mortality. Surgery (eg transplantation, mechanical assist devices) has a definite place in young patients with chronic dilated cardiomyopathy with severe heart failure although other therapeutic agents (eg growth hormone, thyroxine and antioxidants) are yet to be shown to be of benefit. Conclusions: Heart failure is a common condition caused by many disorders leading to left ventricular dysfunction. Management of the underlying disorder (eg ischaemia, valvular disease, hypertension) maintenance of sinus rhythm, as well as reducing excessive neurohumoral activation (ACE inhibitors, angiotensin receptor antagonists, beta-blockers, spironolactone) can reduce mortality and improve morbidity in patients with chronic heart failure. (author abstract)